QI Plan Part 4 and Executive Summary

Implementing a new system in place needs a sense of teamwork within the staff and leadership of an organization. The leaders involved in the fulfillment of a quality improvement plan include the board of directors, the departmental staff, the QI committee as well as the middle management. It is also essential to have an efficient communication mechanism amongst all the leaders and staff in the facility, the vendors, and the end users as well. Such process will ensure that the new system will effectively communicate with the current operational system, as such; data would transfer without any issues or losses.

This paper aims to discuss the criteria, tasks, communications, education, monitoring and revisions, a well as regulatory and accreditation involved in a successful creation and implementation of a quality plan. Comment by Lawrence Fergus: Good overview and alerting the reader what to expect in the body of the paper.

Criteria and Tasks

The primary component of any given QI plan must include a detailed explanation of the goals the purpose as well as the policies that the organization intends to achieve. It also requires a detailed outline of the committee’s roles and responsibilities as well as an account of all the systems and measures needed to achieve the plan (Health Resources and Services Administration, 2015). Quality improvement entails some functions that would need careful delegation to each of the stakeholders involved. For instance, the leaders play a critical role since they are in charge of establishing and maintaining a personal as well as an organizational emphasis towards both the internal and external demands of clients (Health Resources and Services Administration, 2015). The leader is obliged to display an unwavering commitment to the purpose, objectives, expectations, and values of the institution. It must ensure that the team attains excellent performance as well as promote quality. The other key roles would include day-to-day leader, provider champion, data specialist, data entry person and operations person (Health Resources and Services Administration, 2015).

Authority, Structure, and Organization

When implementing a quality improvement plan, it is critical that the organization establishes mechanisms of achieving its goals and objectives within the authority structure. In that case, the organization would have to analyze and outline staff body so that there would be a clear understanding of individual’s goals and ensuring that they concur with the organizational goals (Godény, 2012).

An organization chart is an organized system that assimilates information, the consumers as well as the technology within the facility to achieve a current goal. The primary objective of Davis healthcare facility is to provide excellent patient care experiences. Each discipline is ranging from the board of directors; employees all have unique roles to play in the improvement plan (Godény, 2012). The organizational structure is an essential element that must be well thought during the implementation of the QI program.

At Davis healthcare, the board of directors has a sole responsibility of ensuring that all the members of staff are giving the patients quality care. The board members must know the relevance of monitoring QI within the healthcare facility, and they also have a duty to ensure that the employees are following all the regulations, and quality standards are met (Godény, 2012). The organization thus needs to involve the board of directors in the implementation of the QI plan.

The board has a legal responsibility for spearheading and monitoring the improvement of the delivery of high-quality patient care (Godény, 2012). The board of the health care facility is responsible for ensuring that the QI plan is designed so that it can perform the following functions:

· Sufficiently monitor the delivery of patient care services as well as make it easier to identify any harmful and risky activities in time (Balestracci & Barlow, 1996).

· Quickly establish opportunities that would drive improvement into the existing operations and systems.

· Assure that effective links between the various activities in the facility are well set up to protect the patients from harm as well as ensure compliance with the current standards of patient care (Safety, quality, credentialing, infection control, risk management) (Balestracci & Barlow, 1996).

· Assure that all the effected changes in the QI plan remain in place through time.

The board of directors has legal obligation related to duty of care, which arise in two primary contexts; the decision-making role and the oversight responsibility. In fulfilling the obligation of care, the board has a responsibility to carry out the due inquiry, make informed and responsible decisions in addition to providing appropriate oversight to the healthcare facility (McLaughlin, McLaughlin, & Kaluzny, 2004). Furthermore, the board is required to provide quality control to the compliance program

Adequate supervision of the program of conformity will require an evaluation of compliance with regulations that govern hospital acquired conditions, the Reporting Hospital Quality Data for Annual Program Update, state adverse event reporting requirements, gain sharing, physician incentives, and outcomes management initiatives (McLaughlin, McLaughlin, & Kaluzny, 2004). A board of directors of an organization is responsible for providing guidance, leadership, and support during the creation and implementation of a quality improvement plan. The board must approve the final QI plan before execution begins. The board of directors also has the responsibility to evaluate periodically and review the plan (Health Resources and Services Administration, 2015). It is the duty of the board to provide and approve the required resources for attainment. It is important for the board to demonstrate a continued interest and involvement in the organization’s quality and improvement processes:

· Executive Leadership – will organize the plan, by pulling managers from clinical, financial and administrative teams to identify potential problems through brainstorming.

· Quality Improvement Committee – will monitor the project to ensure that early warnings for identifying and avoid potential liability resulting from actions.

· Medical Staff – will determine the cause of the increase in medication error over the past 3months and in order to prevent/reduce medication errors from occurring, will provide data during the Quality Improvement (QI) process and provide data to middle management for accuracy (Godény, 2012).

Leadership and structure. A quality improvement plan needs, to begin with, an individual or committee are responsible for creating, implementing, and monitoring the program (McLaughlin, McLaughlin, & Kaluzny, 2004). It is essential for a clear comprehension of the roles and responsibilities to be defined as well as accountability. A QI plan consists of members from executive leaders and clinical staff (Health Resources and Services Administration, 2015).

Communication. Once a QI plan has been established, it is critical that the facility sets up routine association on quality enhancement to all the employees inclusive of the board and all the prospective stakeholders (Balestracci & Barlow, 1996). There is a need for consistent appraisal on how these initiatives are established and implemented; the training activities that is in progress; and the quality improvement charting; as these are crucial components of any communication process (Godény, 2012). “The progress in most Quality Improvement at Davis health care facility will be documented using event logs, issue identification records, meeting minutes, among others.  Development efforts could also be communicated through the various mechanisms, such as kick-off meetings or all-employee meetings; storyboards and/or posters displayed in common areas; sharing organization’s annual QI plan evaluation; e-mails, memos, newsletters and/or handouts; and informal verbal communication (McLaughlin, McLaughlin, & Kaluzny, 2004).”

A QI program should be examined yearly to ensure efficiency in attaining the purpose. A QI council will evaluate annually and create recommended modifications to the QI program (Health Resources and Services Administration, 2015). “Based on an ongoing review, priorities will be set, and opportunities for improvement identified for the next year (McLaughlin, McLaughlin, & Kaluzny, 2004).”

Monitoring relays a method for identifying the comparativeness of the organization with the first opportunities for improvement and attaining of set goals and objectives (McLaughlin, McLaughlin, & Kaluzny, 2004). All areas need control since any defect in service delivery to a patient would affect the whole healthcare facility. Leaders determine the specific areas that require monitoring (Health Resources and Services Administration, 2015). Monitoring could be aimed at improvement, ensuring policy compliance or establishing the procedures and standards in the installation.

Regulatory and Accreditation. The accrediting and regulatory agencies that would be involved in the Quality improvement processes include: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the United States Department of Health and Human Services (HHS) and the National Committee for Quality Assurance (NCQA) (Health Resources and Services Administration, 2015). JCAHO is responsible in assessing the standard of care that patients receive. The agency requires that all health organizations’ management set expectations, plan and manage the measurement, assessment, and improvement of all the aspects of providing healthcare (Health Resources and Services Administration, 2015).

The HHS is usually the representative body for the federally funded agency, which focuses on improving the quality of healthcare. The federal government defines and mandates the specific areas for monitoring Quality (Health Resources and Services Administration, 2015). Such include preventive care, chronic disease management, and infection control and fall rates.

Conclusion

In every successful quality plan, are involved and committed stakeholders. Stakeholders have their own roles to perform in order to achieve the ultimate purpose of quality processes, that which is to provide excellent health care service to those who are need.

This paper tackled and elaborated the criteria, tasks, communications, education, monitoring and revisions, as well as regulatory and accreditation involved in the effective development and implementation of a quality plan. Comment by Lawrence Fergus: Well summarized

References

Balestracci, D., & Barlow, J. L. (1996). Quality Improvement: Practical Applications for Medical Group Practice. Medical Group Management Assn.

Godény, S. (2012). Quality assurance and quality improvement in medical practice. Part 3: Clinical audit in medical practice. Orv Hetil , 153(5):174-83.